People go to medical school because they want to help others. When they become physicians, they take an oath promising to do no harm. So when something goes wrong and a patient is hurt, doctors take the news especially hard.
Laurie Drill-Mellum, M.D., understands this reality better than most. An emergency medicine physician and chief medical officer of Constellation, a Minneapolis-based collective of medical malpractice insurers, she leads a team of experienced physicians who provide emotional support to doctors and other care providers who have experienced adverse medical events or are facing patient-led litigation.
Drill-Mellum believes that this unique service, available to physicians and other care providers covered by a Constellation company, can be key to keeping medical staff feeling mentally healthy and prepared to continue serving their patients in the best manner possible.
“Unlike a lot of other people whose identities aren’t as tied to their profession, a physician’s ego is deeply entwined with what they do and with the patients they serve,” Drill-Mellum said. “We are the only profession that is expected to bat 1000 every single day.”
When a serious, harm-causing error occurs, these outsized expectations can feel like a heavy burden, Drill-Mellum said, adding stress to shoulders already weighted down with a sense of duty and a commitment to patient care.
“Physicians are asked to be perfect in an imperfect world,” she said. “There is no way a physician can practice medicine and not be a witness to, a cause of or a part of something going wrong at least once in their career. Even so, when that happens it just tears us up inside.”
If the guilt of causing or being part of a medical error isn’t enough, add to that the shame of being named as a defendant in a lawsuit. Kaz Nelson M.D., vice chair for education in the University of Minnesota’s Department of Psychiatry, said that patient-initiated litigation, while an important part of the legal process, is a source of pain, anxiety and deep embarrassment for many medical professionals.
“Physicians think, ‘If I work hard enough, if I try hard enough, if I burn the candle at both ends, then I should be able to prevent mistakes,’ ” she said. “When something bad actually happens, it reflects on you, you’re falling short, you didn’t do that perfectly: No one wants that to happen.”
When an error triggers a lawsuit, Nelson added, “It almost becomes too much for some physicians to bear.”
By providing peer support, Drill-Mellum said, she hopes to make the load feel a little lighter for health care providers. She wants questioning practitioners to understand that their careers can continue even after traumatic experiences.
Only connect
When a medical error or concerning incident is reported to Constellation, the information is passed to a claim consultant who connects the clinician with a peer support physician.
“We have a team which consists of four doctors that are experienced physician leaders,” Drill-Mellum said. “They’ve been trained in responding to situations where physicians or other clinicians are under stress. They are really good listeners. They’re there to support and normalize the feelings that people are having.”
Loie Lenarz, M.D., former medical director of clinician professional development for Fairview Health Services, is one of Constellation’s peer counselors. Now retired, she was a practicing family medicine physician for more than 30 years.
When she’s given the name of a peer who needs support, Lenarz reaches out, usually with a text or an email, offering a phone conversation or a personal meeting. More than half the time, she doesn’t hear back after that first contact.
A week or two later, Lenarz reaches out again. “I’ll say, ‘I don’t mean to be a pest. But I want you to know that I’m available. Let me know when you’d like to talk, or if you don’t need to talk to me, you can tell me that, too.’ After that second contact, most call back.”
The resulting conversations vary in length, but tend to have a similar theme.
“On that very first phone call, one of the things I talk to them about is the support resources they have available,” Lenarz said. “In an open-ended way, I ask them if they feel like they have the support they need in their lives. I might say, ‘Your support could come from family or friends. It might be your faith community or seeing a counselor. Do you have what you need?’ Most people I talk to say they are glad we talked, that it helped them feel supported through this traumatic experience.”
Clearly physicians understand that things can go wrong in any medical procedure, but more often than not procedures go as planned, and no one gets hurt. When a patient is hurt, it is almost as if the practice of medicine has been put under an X-ray, revealing all the potential dangers that exist just beneath the surface.
This can be a confidence-crusher, Lenarz said, undermining a practitioner’s ability to make key decisions under pressure. It’s hard to prepare for this situation until it happens, she added: Physicians who have been sued are far more likely to be sued again over the next few years because they lose confidence, questioning their ability and overcompensating with tests and consultations.
“One doctor I was working with said, ‘In spite of all I know about what happens to physicians in these situations and how we start to doubt our ability and over-order tests, it’s still happening to me. I can’t seem to make it not. I’m wondering if I should still be a doctor,’ ” Lenarz recalled. “This woman was smart and self aware, but in spite of that she was still feeling that way. My job was to support her, to listen, to help her get past that roadblock so she could keep working.”
Shift to apology
In the not-so-distant past, doctors and other health care professionals were cautioned to never admit fault when they spoke with patients about medical errors. That very admission, they were told, even if the care provider was the one who caused the harm, could leave them vulnerable in a legal battle — and even cause them to lose their license.
That “us vs. them” attitude is slowly changing, Drill-Mellum said. At Constellation, rather than encouraging blanket denials or zero communication with patients, staff is working with providers to reach out to patients who have been harmed, to provide sincere and honest apologies when appropriate, and to encourage open communication around the trauma.
“This is radical in malpractice work,” Drill-Mellum said. “We come from a long history in the profession of ‘deny-and-defend’ medicine. But we no know that is harmful, not only to the patient and the family, but also to the physician.”
Nelson said that the move toward open communication and apology is healthy for everyone. “Deny and defend” created a false sense of oppositional sides, when the truth is that most everyone involved in such cases had one goal in mind: supporting the health of the patient. Coming around to that understanding is an emotionally healthy response.
“Malpractice folks used to be bad at this,” Nelson said. “They used to say, ‘Don’t say you’re sorry,’ but even so, everyone was still getting sued a lot. Then, some really bright thinkers said, ‘When there is an error we have to disclose it in a way that shows our caring and compassion and regret. We need to apologize.’ That has actually led to a decrease in litigation. People are starting to understand that mistakes happen.”
If honest apology factors into reduced litigation, it only makes sense that malpractice insurers would encourage the practice. There is not only a moral benefit to apology, but a financial one as well.
“In situations where we find that malpractice has occurred we will be engaging in early offers of resolution to shorten the life cycles of these claims and get people healing,” Drill-Mellum said. “When something bad happens and it ends up in litigation, it delays healing for everybody. We have we an interest in moving toward healing and resolution to the extent possible.”
Apology can take different forms, Drill-Mellum said, but all can have a healing effect.
“There are different kinds of apologies. There is an apology of regret, like, ‘I’m sorry this happened to you.’ There can be an apology of remorse, like, ‘I did something wrong and I’m sorry you suffered from it.’ We always encourage practitioners to apologize for something that happened. That doesn’t always mean that anyone is at fault.”
The old approach to post-incident conversations made patients feel like they were being shut out, Nelson said. That added to a sense of wanting to pursue litigation or use other means to get their needs met. The more open approach to communication acknowledges the humanity of all involved in the medical process. For patients, this may create a sense of psychological resolution that is more important than any financial award. For care providers, this may engender self-forgiveness.
Playing a role in an adverse medical event, Nelson said, “doesn’t have to mean you’re a bad doctor. It means you had a blind spot, a protocol that was lacking in some way or maybe a system precipitated an error. Lots of different steps contribute to the delivery of health care. When we realize this, when we forgive ourselves and others, we can move on.”
The power of honesty
If apology and forgiveness are important steps in moving past and even reducing medical error, another key step may involve physicians and other health care providers telling the truth about their own past mistakes.
We’ve all heard the saying, “everybody makes mistakes,” but for medical professionals, it can be hard to admit error, mainly because it signals weakness in a profession that requires a level of ego and confidence.
“Some providers may not want to make themselves vulnerable by talking about these kinds of incidents,” Drill-Mellum said. “There are some physicians that we’ve worked with who went to work on their court dates in their work clothes and then changed into their suit in the bathroom. They didn’t tell their partners or their families that they were being sued. There is a profound amount of shame that makes even talking about this just too difficult.”
Drill-Mellum and her colleagues are trying to change that. They believe that being open about their own past errors may help reduce feelings of shame for others.
“I myself have been sued,” Drill-Mellum said, adding that she makes a point of letting her colleagues and others know about this fact. “There are a lot of emotions that you go through in these kinds of situation. You can experience anger, fear, shame, embarrassment, even feelings of wanting to quit. By talking about it, I was able to get past it and continue on with my career.”
Lenarz still carries the pain of the death of a newborn in her care. This happened decades ago, but she’ll never forget it. She explains that these feelings are called “secondary trauma.”
“The system failed a patient and she lost her baby,” Lenarz said. “I know the wrenching heartache that case caused. It impacted my work for years afterward. Incidents like these can cause a physician to question their capacity and their ability as a professional.”
Lenarz understands that her own openness and honesty about her experiences aids the professionals she counsels. It also helps her get past her own secondary trauma — and incorporate the lessons it provided into her medical practice.
“I’ve witnessed the redemption that can occur when you directly address your past errors,” Lenarz said. “I try to explain that to the doctors I support.”
As a mental health care provider, Nelson has a deep understanding of the power that comes when a person acknowledges their failings. In her role at the U of M, she tries to teach medical students that as well, modeling honesty, a willingness to discuss failure and the power that approach brings.
“One thing that we can do with learners is to battle shame by disclosing if you’ve had litigation brought against you,” Nelson said, “to normalize it so when that happens to them, they won’t feel so alone.”
Error is inevitable, Nelson said, but if we do everything possible to reduce the harm it causes, medicine may become safer for everyone.
“Physicians are just human beings. We like to portray ourselves as superhuman, but the truth is we are not. From the patient perspective, it’s kind of scary to think that your physician is human, but we are. We’re just like everyone else, and for good or bad we all make mistakes.”
